Payer organizations (payers) employ claims rules used for determining whether, and how much, to pay on a claim for reimbursement of healthcare costs for a patient. The claims rules are specific to each payer organization and are tailored to specific healthcare providers (i.e. a hospital, a physician) according to contractual terms in agreements. These terms may vary between individual contracts which limit use of universal rules applicable to all contracts. In the absence of comprehensive knowledge of these rules, claims submitted to payers for payment are often rejected. Claim rejections typically begin a long cycle of correction and resubmission, costing the healthcare provider both time and money in trying to collect what is owed to them.
When a patient receives healthcare services (e.g., a diagnostic X-Ray) the provider of those services sends information to the patient payers (e.g., their insurers) requesting to be reimbursed. Payers require that the information sent to them be formatted in a specific way (this formatting can vary by individual payer). Payers may also require different payer specific information to be sent, depending on the services that have been rendered. If the information sent to the payer is incomplete, or is not formatted correctly, the payer rejects the claim via an EDI (Electronic Data Interchange) 835 transaction remittance advice (RA). The provider attempts to edit the claim to provide the correct data in the correct format, and resubmits the edited claim to the payers. In response to submission of correct claim data, the payer may reimburse the provider, and send back an electronic notice of this reimbursement, also in the form of an RA. If the reimbursement amount is less than the provider charged for the service, the provider may submit a secondary claim to a different payer for the un-reimbursed amount. Healthcare providers including, hospitals, facilities, clinicians, and billing services typically experience a high claim rejection rate since they often submit claims with financial data that does not comply with payer rules and regulations resulting in substantial delay in fee collection. Turnaround times for claim reimbursement of 30 to 45 days are common and costly for providers.
Known systems often send inaccurate claims to payer organizations, wait for them to be rejected and serially fix the claims rejections. Alternatively, known systems send claims to a third-party, called a “Claims Scrubbers” that has its own set of payer rules and has some limited edit capabilities to fix problems using manual intervention before sending the claims to a payer. However, much time is wasted in this serial and iterative method for submitting claims and receiving rejections and partial payments involving claim correction and resubmission and payer rules are difficult to obtain and maintain. A system according to invention principles addresses these deficiencies and related problems.